A prospective, randomized study using transdermal electromotive administration of verapamil and dexamethasone for Peyronie's disease

‘Off-label’ drug use in sexual medicine treatment

Phosphodiesterase type 5 inhibitors are the only drugs approved for a specific sexual function disorder. All other drugs used in the treatment of sexual disorders are used 'off-label.' This paper reviews the use of drugs in the treatment of premature ejaculation, Peyronie's disease and female hypoactive sexual desire disorder (HSDD). While the treatment of premature ejaculation is quite well documented and supported by evidence of good quality in the medical literature, there is little evidence for the use of the variety of medications in use for the treatment of Peyronie's disease. In particular, the use of verapamil is not supported by any double-blind studies whatsoever. The use of testosterone patch for treatment of HSDD in postmenopausal women is well documented, but not in premenopausal women.

Verapamil versus saline in electromotive drug administration for Peyronie's disease: a double-blind, placebo controlled trial

PURPOSE

While surgery remains the gold standard of therapy to correct the acquired curvature of Peyronie's disease, the search for a less invasive therapy continues. Transdermal drug delivery was proposed to be superior to oral or injection therapy because it bypasses hepatic metabolism and minimizes the pain of injection. After electromotive drug administration with verapamil tunica albuginea specimens were demonstrated to contain detectable levels of the drug. Due to varying success with verapamil as injectable therapy for Peyronie's disease we performed a double-blind, placebo controlled trial to determine the effectiveness of verapamil delivered through electromotive drug administration.

MATERIALS AND METHODS

A total of 42 men with Peyronie's disease volunteered to participate in this study, which was approved by our institutional review board. A genitourinary examination was performed on all patients, including plaque location, stretched penile length, objective measurement of curvature after papaverine injection and duplex ultrasound. Each subject was randomized to receive 10 mg verapamil in 4 cc saline or 4 cc saline via electromotive drug administration. A Mini-Physionizer (Physion, Mirandola, Italy) device was used at a power of 2.4 mA for 20 minutes. Treatments were performed 2 times weekly for 3 months. After 3 months each patient was reevaluated with physical examination and duplex ultrasound by a technician blinded to the treatment received. A modified erectile dysfunction index of treatment satisfaction questionnaire was also completed by each patient.

RESULTS

A total of 23 patients were randomized to the verapamil treatment group (group 1) and 19 were randomized to the saline group (group 2). There were no significant differences between patient groups with respect to patient age, disease duration or pretreatment curvature. In group 1, 15 patients (65%) had measured improvement (mean 9.1 degrees, range 5 to 30), 5 (22%) had no change and in 3 (13%) the condition worsened. In group 2, 11 patients (58%) had measured improvement (mean 7.6 degrees, range 5 to 30), 7 (37%) showed no change and in 1 (5%) the condition worsened. To better evaluate effectiveness the total number of patients experiencing significant improvement (20 degrees or greater) was calculated and compared. Seven patients (30%) in group 1 and 4 (21%) in group 2 achieved this criterion. Although a greater percent of patients treated with verapamil had improved curvature, the results were not statistically significant.

CONCLUSIONS

Although a greater percent of patients treated with verapamil in our electromotive drug administration protocol had a measured decrease in curvature, the results were not statistically significant. Further research is necessary to determine whether electric current may have a role in the treatment of Peyronie's disease as well as if verapamil delivered via electromotive drug administration may have a role as effective treatment. Electromotive drug administration is a treatment option in the patient whose major complaint is pain or in the patient with mild curvature who does not wish to undergo intralesional therapy or surgical correction.

The medical management of Peyronie's disease

There are a wide variety of medical treatments that are available to the practicing urologist, including oral agents, topical creams and gels with or without iontophoresis, intralesional injection therapy, radiation therapy, extracorporeal shockwave therapy, and laser therapy. Medical management of Peyronie's disease might be a valuable treatment option for this debilitating disorder, especially in the early symptomatic stages of the disease. Although no single modality has been demonstrated to have superior efficacy, intralesional therapy appears to confer some benefit. Multicenter, large-scale, randomized, controlled studies are necessary to fully establish the efficacy of the available treatments. Until such trials are conducted, a rational approach involving combination therapy is the most appropriate method to treat these patients. In this Review, the current medical treatment options available for the management of Peyronie's disease are discussed and a management algorithm is proposed.

New Frontiers in Intravesical Therapies and Drug Delivery

OBJECTIVES

The intravesical route permits site-specific delivery of drugs with a reduced side-effect profile as compared to oral delivery systems, either by avoiding first-pass metabolism or by obtaining a local effect. We investigated mechanisms related to urothelium permeability and new physical and chemical developments in intravesical drug delivery that potentially permit successful treatment of several bladder dysfunction.

METHODS

A literature review.

RESULTS

Pharmacologic agents increasing urothelial permeability and useful for clinical purposes have been described, such as dimethylsulfoxide, protamine sulphate, chitosan, and nystatin. Among physical approaches, electromotive drug administration appears to be more effective than intravesical passive diffusion in delivering drugs through the urothelium into deeper layers of the bladder. Experimental and clinical reports demonstrated that electric current significantly increases the transport of local anaesthetics, mytomicin C, oxybutynin, resiniferatoxin, epinephrine, and dexamethasone. Among new chemical approaches, cell-penetrating peptides posses the ability to translocate macromolecular drugs across membranes of urothelial cells. The therapeutic benefits of sustained delivery afforded by thermosensitive hydrogel, which forms a depot for hydrophilic and hydrophobic drugs, have been demonstrated by delivering anti-inflammatory drugs. Liposomes improve the aqueous solubility of several hydrophobic drugs such as taxol, amphotericin, and capsaicin.

CONCLUSIONS

Electromotive drug administration, new in situ delivery systems, and bioadhesive liposomes may make it possible to extend intravesical therapy and drug administration to many bladder diseases. Research to expand knowledge of the chemical and physical properties of the bladder and processes regulating drug transport across biologic membranes is needed to make this a reality.

A Critical Analysis of Nonsurgical Treatment of Peyronie’s Disease

OBJECTIVE

Because the efficacy of nonsurgical therapy of Peyronie's disease is controversial, this review analyses the current status of conservative therapy of Peyronie's disease.

METHOD

A systematic survey on results of studies published as original papers in peer-reviewed journals is provided.

RESULTS

Oral drug therapies include potassium para-aminobenzoate (Potaba), vitamin E, colchicine, tamoxifen, propoleum, acetyl-L-carnitine, and propionyl-L-carnitine. Verapamil, interferon-alpha2a and interferon-alpha2b, collagenase, cortisone, hyaluronidase, and superoxide dismutase are considered intralesional therapies that have had various degrees of success. Other treatments include local gels, iontophoresis, extracorporeal shock wave therapy, and radiation.

CONCLUSION

This review analyses the current status of the conservative therapy of Peyronie's disease, because the efficacy of the nonsurgical therapy is controversial.

Peyronie's disease: etiology, epidemiology and medical treatment

The investigation of medical options for the treatment of Peyronie's disease is lacking controlled clinical trials with uniform standardized assessments and objective measures of deformity, including curvature and circumference. A key to defining the beneficial effects of various medical therapies lies in standardizing the evaluation of the Peyronie's patient across various studies so that the proposed benefits can be confirmed and applied to all populations. Furthermore, basic science research into the pathophysiology of this disorder is likely to yield new insights into potential treatment options and direct future therapies.

Conservative management options for peyronie’s disease

Peyronie's disease is an acquired condition that presents clinically with a palpable induration, a distinct plaque, or a curvature of the erect penis. At times, the erections are painful. Erectile dysfunction (ED) often is associated with Peyronie's disease. The current era of phosphodiesterase therapy for the treatment of ED seems to have increased the number of patients presenting for treatment of Peyronie's disease. During the past decade, significant advances have been made in understanding the pathophysiology of the disease, resulting in numerous nonsurgical therapies proposed for the treatment of Peyronie's disease. These medical treatments can be administered systemically, locally, or intralesionally. Unfortunately, there are few randomized, placebo-controlled trials to evaluate most of these proposed therapies. In evaluating therapies for Peyronie's disease, it must be remembered that the natural disease history includes spontaneous resolution of pain and even a small improvement in penile curvature in some men. This article reviews the natural history, scientific understanding, and nonsurgical treatment options for the mild to moderate Peyronie's deformities. Surgical therapy remains the mainstay of treatment for severe and refractory cases of Peyronie's disease that result in a physical or psychologic dysfunction.

Liposomal Recombinant Human Superoxide Dismutase for the Treatment of Peyronie's Disease: A Randomized Placebo-Controlled Double-Blind Prospective Clinical Study

OBJECTIVE

To demonstrate the efficacy and safety of a topical gel containing liposomally encapsulated recombinant human Superoxide Dismutase (lrhSOD) in the treatment of painful Peyronie's Disease. The theoretical background is that lrhSOD, by scavenging of free oxygen radicals, might interrupt inflammatory cascades and thereby limit further disease progression.

METHODS

In a placebo-controlled randomized clinical trial, 39 patients with Peyronie's Disease and significant pain symptoms were treated with lrhSOD or placebo for a 4 week period. At this time, statistical evaluation of pain resolution was performed as primary study endpoint. Patients then were continued in a cross-over study design to ensure a total of 8 weeks of lrhSOD therapy for all study participants. Pain, plaque and curvature assessment was performed at study entry and every 4 weeks until week 12.

RESULTS

LrhSOD treatment resulted in a statistically significant reduction of pain (p=0.017) compared to placebo already after 4 weeks. At week 12 pain was significantly reduced in 89% of patients who all had received 8 weeks of lrhSOD therapy at that time. Response to other disease parameters was assessed at week 12: plaque size was reduced in 47% of patients, as was plaque consistence in 38%. Penile curvature was improved at 5-30 degrees in 23% of patients. The expected spontaneous disease progression rate of up to 40%, as reported by several investigators, was significantly reduced to <10% under lrhSOD therapy, and patients satisfaction was high, also consequent to the lack of therapy-related side effects observed in the present study.

CONCLUSION

LrhSOD is an easily administrable, safe and effective local therapeutic for the painful phase of Peyronie's Disease.

Psycho-biological correlates of rapid ejaculation in patients attending an andrologic unit for sexual dysfunctions

INTRODUCTION AND OBJECTIVES

Rapid ejaculation (RE) is the most common sexual dysfunction in males. The aim of the present study is to determine the contribution of intrapsychic, organic and relational factors to the pathogenesis of RE and the relationship between RE and erectile dysfunction (ED) in a sample of patients attending for the first time to an Outpatient Clinic for sexual dysfunction.

METHODS

We studied a consecutive series of 755 patients using Structured Interview on Erectile Dysfunction (SIEDY), a brief, recently validated, multidimensional instrument specifically designed by our group for the study of pathogenetic factors of ED. RE was defined as ejaculation within 1 minute of vaginal intromission and its severity was categorized on a 4-point scale using a standard question. A complete physical examination and a series of biochemical, hormonal, psychometric, penile vascular and rigidometric evaluations were performed.

RESULTS

Twenty-eight percent (n = 214) of patients attending to our sexology clinic reported RE of any degree. Patients reporting RE were younger (48.5 +/- 12.6 vs. 52.9 +/- 12.9 years old for RE and not RE respectively; p < 0.0001) and showed a higher prevalence of anxiety symptoms when compared to the rest of the sample. Among organic factors subjects with RE showed a higher prevalence of hyperthyroidism and significantly lower fasting plasma glucose (94 [87-110] and 98 [89-113] mg/dl for RE and non-RE respectively; p < 0.01). No difference among groups was observed for other hormones or clinical, biochemical and instrumental parameters. Finally RE patients showed a higher prevalence of partial erection sufficient for penetration when compared to the rest of the sample. Similar differences were observed between patients with and without RE when those without ED were excluded from the analysis.

CONCLUSION

Our data suggest a minor involvement of organic factors to the pathogenesis of ED in patients with concomitant RE. On the other hand, in our sample, patients complaining about RE are younger, healthier than the rest of the sample and are characterized by high degree of anxiety symptoms and hyperthyroidism.

Iontoforesis transdérmica con dexametasona y verapamilo para la Enfermedad de La Peyronie

OBJECTIVES

To evaluate the effects of transdermal iontophoresis with verapamil and dexamethasone in patients with Peyronie's disease of less than one year of evolution.

MATERIAL AND METHODS

We have treated ten patients twice a week during six consecutive weeks using iontophoresis with a Miniphysionizer dispositive. This device generates a 2mA electric current during 20 min which triggers the transdermal penetration of medication. In every session dexamethasone 8 mg and verapamil 5mg were administered inside a small self-adhesive receptacle on the penile skin overlying the fibrosis plaque. To evaluate the efficacy, penile curvature was measured by Kelami's test, while the plaque size was assessed by penile ultrasound. Other parameters like pain, erectile function and ability for vaginal intercourse were recorded using questionnaires. Safety parameters were also assessed during treatment.

RESULTS

No improvement or progression in penile curvature was evidenced in any of the patients. The hardness of the plaque was reduced in 5 patients, becoming impalpable in 2 of them. Decrease in plaque volume was observed by penile ultrasound in 6. Pain improved in 8 patients, disappearing in 6 of them. One patient recovered his erectile function at the end of the treatment; whereas 3 referred that their ability for intercourse enhanced while 2 reported that treatment improved their sexual life in general. We didn't record any significantly side effects, except for a transitory and slight dermal redness on the site of electrode placement.

CONCLUSIONS

Transdermal iontophoresis is an effective treatment for pain control in early stages of Peyronie's disease. Efficacy in reducing penile curvature seems to be limited. Controlled clinical trials are needed, and perhaps reviewing indications in order to obtain more relevant clinical effects.